HomeMy Public PortalAbout9171 BIDWELL ST_Electrical__ WORKER'S COMPENSATIONoats of consent to ,OW- -, (12-91) APPLICATION FOR ELECTRICAL PERMIT
I hereby affirm that I have a oertlfloate of consent to self Insure, ..
or a cerUfloate of Worker's Compensation Insurance, or a certlfled *COtl J1TY OF LOS ANGELES DEPT. OF PUBLIC WORKS BUILDING AND SAFETY DIV.
copy thereof(Seo.3800 Lab.C.)
Policy No. Comperry PDR APPL)CA)rr To F11-1-IN GJG C L
LrJI Certified copy Is hereby fumlet}ed. New Raaldentlal Bldpa S Pools NO. EACH FEE LOCALrFY
❑ Certl-fed copy Is flied with the county buDdN Inspection 1 A 2-Family,Sq.FL — $ _ rFA 5EST
deputn—t Multl-tamlly Sq.Ft. pipes 8T.
Data rt RgafdefTtiLI 8wlrnming POOIe Mp BOOK PAGE I PAFlCEL
CERTIFICATE OF EXEMPTION FROM WORKERS' Oubeta:R¢c._Ught Sw. =M
COMPENSATION INSURANCEFi 20 M&rL rL11aE
(This section need not be completed H the work Involved by the Total No. Addttlonal I Z7! w i G K-
permit Is for one hundred dollars($100)or lass.)
1 certify that In the performance of the work for which this permit C" —% /" . TOL Ho ^s
Is Issued, I shall not employ any person In any manner so as to PLAN CFE
become subject to the Worken'GompeUA&4n Laws. Ughting Fbctures Fret 20 APPLOC Nr
Total No. Additional
Data 2-2-6 -�� ADDRESS
RESIDENTIAL APPLANCES NOT OVER 3 HP.
NOTICE TO APPLICANT: If, a r making thls Certificate of CITY TOL No.
Exemptlon,you should become jeot to the Worker' Compensatlon OTHER APPLIANCES NOT OVER 3 HP.
provisions of the-Labor Code,you must forthwtth comply wlth such
provialons or this permit shall be deemed revoked. Power Apparatus A Large Appllancee
APPLICANT 10
LICENSED CONTRACTORS DECLARATION Stxe A Type HP,KW,KVA.or KVAR ADDRESS 01 8r)
I hereby affirm that I em licensed Under provisions of Chapter B Over 3 to 10 Inoi. CfTy�G
(commanoing with Section 7000) of Dlvislon 3 of the Business and L ^P
Professions Code,and my Iloenee Is In full force and effect. Over 10 to 60 Ind. LtcaBEOR
Q y Over 60 to 100 Inol. REG.NUMBER �'�7
9 j Ll a+ � O„er 100 DOTwcT NO. m BY
O
Uce{iee Number LJc.ease
{� / pp// Sery/lp,q�/�,� Panelboards a U
Contractor / �� /C Data 7— 6 "-71y /'�'OYWunder 800 V ( ANTE
❑ I am exempt under Sec. 400-1000 Amp.Under 000 V '/ —�
Over 1000 Amp.or Over 800 V VAIJDATION W
FINAL By fZ
B.AP.C.for this reason BRANCH CIRCUIT FEES co
Dete: 16A,or 20A.120V,Ulghting or Re(ep I Z
1 To 10 Branch Chcufts
Signature 11 To 40 Branch arou is
41=
Moro Breach arauls
❑ Exemptfdn for Rep.Melrrt.Elect. 16A.20A,206V To 277V Br.Cirauftn n��-�+
SINGLE FAMILY Temen
p.Power Pole A Appurtanoee ACCT.i
HOME OWNER-BUILDER DECLARATION mon,Mit,One
I hereby affirm tem exempt I eexempt from the Contractor's Ucense BranchLaw arouh 66.60
for the following reason (Section 7031.6, Bualneas and Professlons Additional Sfgn Branch CIrcults
C(>de): i ITM
❑ I,an owner of the property, will do the work and the structure Misc.Condults A Conductors y TOTAL 6 61D
Is not Intended or offered for sale (Seotlon 7044, Business Other(See Complete Fee Schedule) ' l+iLr�fi! .LL� ��Un�1
and Profsaslons Code). (I-E.CK 6.5.60
CONSTRUCTION LENDING AGENCY 4f1 4GE .L1U
1 herby affirm that there Is a construction lending agency for the
performance of the work for which this permit Is Issued (Sec. 3087, PERMIT FEE (Sub-Total) �p
Civ.C.) ODOR-OW 1 2/26/96
PLAN CHECKING FEE
Lenders Name PLAN
5012 O 1 AM-9:03
PERMFF ISSUING FEE
Lenders Address
I oerttfy that I have read this applloadon and under penalty of purjury state TOTAL FEE
that the above hfomwtkm Is correct. I agree to comply with all County
ordlnanoee and 8tate laws regulating Electkel wiring,and hereby authortre
of thla County to enter upon the above-mertHor»d property
f SEE REVERSE FOR EXPLANATORY LANGUAGE
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